Single Lumen Extrusion Request Form
PART ONE - ORDER INFORMATION
Date       Phone      
First Name      Last Name
Company / Address      Street       
Address     State      Zip      Country
Product Application
Request Category Best Effort      Development      Trial      Production      OQ / PQ      Validation     
Purchase Order #   Reference Document(s)
PART TWO - MATERIAL DESCRIPTION
WT%
POLYMER TYPE
TRADE NAME
GRADE NUMBER
ADDITIVE / COLORANT
%
%
%
%
PART THREE - PACKAGING
Final Quantity
[Select One Only]
 Qty Reel(s)         Length on Reel each 
——— OR ———
Qty of cut Pieces Piece Length
PART FOUR - PRODUCT SPECIFICATION

Single Layer Extrusion
 ID
OD
Wall (W1)
Concentricity

Greater than or eqaul to              Maximum Ovality   Less than or equal to

Physical Properties Tensile Stress                                                Tensile Strain ( Elongation )
@ Max Load        @ Break
Comments 
You will receive a cost quotation via email within 24-36 hours or less.